A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

Inform the client that the nurse will get reprimanded for not administering the medication

Document the client’s refusal on the medication administration record

Ask the client the reason for refusing the medication

Inform the client that refusal is not permitted and it is required that the client take the medication

Answer and Explanation

The Correct Answer is C

Choice A reason: Informing the client about potential nurse reprimands is coercive and inappropriate, as it prioritizes the nurse’s interests over patient autonomy. This approach fails to explore the client’s reasons for refusal, which may involve side effects or mistrust, and does not support therapeutic communication or ethical care.

Choice B reason: Documenting refusal is necessary but not the first action. Exploring the reason for refusal allows the nurse to address concerns, potentially resolving issues like misunderstanding or side effects. Documentation follows after attempts to understand and educate, ensuring a therapeutic approach before recording the refusal.

Choice C reason: Asking the reason for refusal respects autonomy and initiates therapeutic communication. It identifies barriers like side effect fears or lack of understanding, enabling education or alternative solutions. This approach aligns with patient-centered care, addressing underlying issues to promote adherence while respecting the client’s rights.

Choice D reason: Stating that refusal is not permitted is coercive and violates autonomy. Clients have the right to refuse medication unless under involuntary treatment orders. This approach damages trust, escalates resistance, and contradicts ethical principles, making it an inappropriate initial response to medication refusal.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Administering IV normal saline addresses fluid volume deficits, not cloudy dialysate, which suggests peritonitis in CAPD. Saline does not treat infection or clarify drainage. Without addressing the potential infection, complications like sepsis or peritoneal membrane damage may occur, making this intervention irrelevant to the finding.

Choice B reason: Flushing the peritoneal catheter with saline risks introducing bacteria or dislodging clots, worsening potential infection. Cloudy dialysate indicates peritonitis, requiring assessment and likely antibiotics, not flushing. This action could compromise the catheter’s integrity and is not a standard intervention for suspected peritonitis in CAPD.

Choice C reason: Cloudy dialysate is a hallmark of peritonitis in CAPD, caused by bacterial infection. Assessing for fever, abdominal pain, or rebound tenderness confirms infection, enabling prompt antibiotic treatment. Early intervention prevents sepsis or peritoneal membrane scarring, which could necessitate dialysis modality change, making this the priority action.

Choice D reason: Continuing to monitor without assessing for infection delays treatment of potential peritonitis, a serious CAPD complication. Cloudy dialysate requires immediate evaluation, as untreated infection can lead to sepsis, peritoneal damage, or death. Passive monitoring risks patient safety, making this an inadequate response to a critical finding.

A. Defense mechanisms can create difficulty with relationships B. Defense mechanisms can lead to poor problem-solving skills C. Defense mechanisms can help a person to reduce anxiety D. Defense mechanisms can inhibit emotional growth

Correct Answer is C

Explanation

Choice A reason: Defense mechanisms, like denial or projection, can strain relationships by avoiding honest communication or projecting blame, disrupting trust and emotional connection. While they may temporarily reduce anxiety, they hinder interpersonal dynamics, making this a negative outcome rather than a positive one in therapeutic interactions.

Choice B reason: Defense mechanisms can impair problem-solving by avoiding reality (e.g., denial) or displacing emotions, preventing rational analysis of issues. This leads to maladaptive coping, which does not address underlying problems, making it a negative consequence rather than a positive outcome of using defense mechanisms in mental health contexts.

Choice C reason: Defense mechanisms, such as repression or rationalization, temporarily reduce anxiety by shielding the individual from overwhelming emotions or stressors. By mitigating psychological distress, they provide short-term emotional relief, allowing the person to function under stress, making this a positive outcome when used adaptively in mental health management.

Choice D reason: Defense mechanisms can inhibit emotional growth by preventing individuals from confronting and processing emotions, leading to unresolved issues. Overreliance on mechanisms like avoidance stalls emotional development, hindering self-awareness and coping skills, making this a negative outcome rather than a positive benefit of defense mechanisms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

Correct Answer is C

Explanation

The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

Correct Answer is C

Explanation

The client states, “I understand that in order to leave, I must sign a request to withdraw from treatment.” What is the client’s legal status?

The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?

A nurse and client are engaged in a discussion. The client says, “I feel really close to you. You are my only true friend.” Which response by the nurse would be most therapeutic?

Which significant change in the treatment of people with mental illness occurred in the 1950s?

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

Which statement by a nurse may undermine a patient’s feelings and belittle the patient’s concerns?

The order is to infuse 50ml of piggyback antibiotic over 1 hour. The set calibration has a microdrip drop factor. What the flow rate in drops per minute?

The nurse is caring for an acutely ill client. Which assessment finding should prompt the nurse to inform the healthcare provider that the client may be exhibiting signs of acute kidney injury (AKI)?